The following is an excerpt from an editorial by Otto Kernberg, M.D. titled: Narcissistic Personality Disorders, PsychiatricAnnalsOnline.com, March 2009.
Chronic Work Failure in Contrast with High Educational Background and Capacity
These are patients who have worked for many years below their level of training or capacity and often drift into a “disabled” status so that they must be cared for by their families (if they are wealthy) or the public social support system. Such a chronic dependency on the family or on a social support system represents a major secondary gain of illness, one of the principal causes of treatment failure. These patients are high consumers of therapeutic and social services. However, were they to get well, they would no longer qualify for the supports that maintain their existence. These patients come to treatment not because they are interested in improving, but to demonstrate to the social system their incapacity to improve and, therefore, their need for ongoing social support. Because they are usually required to be in some kind of treatment in order to get supportive housing, Social Security benefits, disability benefits, etc., they go from program to program, therapist to therapist. Michael Stone, a senior member of our Personality Disorders Institute at Cornell, has concluded that if a patient were potentially able to earn by working at least 1.5 times the amount of money that he is receiving from social support systems, there may be a chance that eventually he will be motivated to work again.
This condition of work failure may merge with grandiose fantasies of capacities and success that remain unchallenged as long as the patient does not become part of the work force. The rationalization of this pattern of social parasitism may include a fantasized profession or talent the patient has and that nobody has recognized as yet: the unknown painter, the inhibited author, the revolutionary musician. Often such a patient is perfectly willing to enter treatment as long as somebody else pays for the treatment, and will abandon it the day when payment is no longer available, even if there existed the possibility of continuing the treatment if the patient were willing to take on employment. The therapeutic approach to such cases needs to include the reduction or elimination of the secondary gain of illness. Clinically, I would point out to the patient that an active involvement in work and its related interactional experiences and/or accepting conceptual-responsibility for financing the treatment are essential for the treatment to help the patient, and that such an engagement is a precondition for the possibility of carrying out a psychoanalytic psychotherapy. Depending on the situation, I might give the patient a period of time to achieve this goal, with a clear understanding that should it not be possible to achieve it, treatment will be interrupted at that point. This condition constitutes a limit setting that will become part of the treatment frame, and therefore, require interpretation as part of its transference implications from the beginning of the treatment. These interpretations may focus on the unconscious motivation for the refusal of work, the importance of the gratification of secondary gain, the resentment the patient may experience toward the therapist’s threat to the patient’s equilibrium, and the self-defeating aspects of the patient implied in his denying himself the possibility of well being, success, self respect, and enrichment of life linked to a potentially successful and creative engagement in a work or a profession.